Healthcare Provider Details

I. General information

NPI: 1578659041
Provider Name (Legal Business Name): MARLINE AMEDEE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 VICTORY RD
QUINCY MA
02369
US

IV. Provider business mailing address

47 HERROD AVE
BROCKTON MA
02301
US

V. Phone/Fax

Practice location:
  • Phone: 671-774-1040
  • Fax:
Mailing address:
  • Phone: 617-774-1040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: